Paediatrics Indonesians' 18' 83 _.::'9o. March - April 1978.

83·

ORIGINAL ARTICLE

Treatment of Acute Infantile Gastroenteritis

. Dehydration Acidosis with Ringer's Lactate
and Glucose-Electrolyte Solution

by

HERNAWAN, SUNOTO, TITUT S. P.USPONEGORO and SUHAR/ONO

(Department of Child Health, Medical School, University

of Indoneszia, Jakarta).

Abstract

Fifty patients hospitalized with severe gastroenteritis - dehydration with

acidosis were investigated. The age average was 8 months with the range of
1 - f 8 months. The amount of the Ringer's lactate solurtvon given was as follows:
1st hour : 30 ml/kg b.w.
the following 7 hours: 70 ml/kg b.w. or 10 ml/kg b.w./hour.
After 8 hours on fi,'litmteTt:d .treatment, the child was given orial solution,
either glucose-electrolyte solution or milk formula in 1;4 dilution.
The mortality rate was 6% (3 out of 50 patients) i.e. one due to seizures
suspected encephal'i!tis, one due rto potasium deficiency (K = 2.1 mEq/1) and
the thi~d due to dehydmtion itself because the child was admirtted already in a
morzbund stage (subvinum vitae}.

Presented at the Second Asian Congress of Pediatrics, Jakarta, 3 • 6 August; 1976.

Received 20th. Dec. 1976.
84 HERNAWAN ET ALi
Introduction
Aou,te infantile gastroenteritis in Indo-
nesia •amd other develop1ng countries is
still one of the major causes of morb1dLty
and mor·taHty in children. The 5 leading
diseases in children in .the Department
of Child· Heaith, Medical School, Uni-
versity of Indonesia . are (Sutejo et al.,
1968):
1. Upper res·p1r;a,tory tract infection.
2. Gastroerute,riti,s.
3. Protein Calorie Malnutrition (PCM).
4. Vittamin A deficiency,and
5. Tuberculosis.
The incidence of gas•troenteritis in
developing countries is estimated as 50 -
70% per 100 population per yeatr and
70 - 80% out of them are children
UJnder 5 years of age, particularly below
2 years (Brotowasi-sto, 1974). The num-
ber of hospitalized patiemtts wi·th gas-
troenteritis- dehyd11ation with acidosis
in the Department of Child Health,
Medical School, Universitty of Indonesia,
Jakarta, in 1975 was 1.127 (22.8%) out
of 4.938 ttotal admissions (Sunoto et al.,
1976).
This f1gure is more or less similar to
other developing countries like Malay-
sia (Abraham and Tan, 1974), India
(Naruka et al., 1974), Puerto Rico (Or-
tiz, 1974), etc.
The mortaHty rate in hospitals is still
very high, and varies from 10 - 20%
(Sutoto et al., 1974; Naruka et al.,
1974), whereas in developed countries
the mortality is 1% (Walker Smith,
1972; Biddulph, 1972).
The cause of this high mor·tality in
developing countries may be due to:
1. The severity of the disease caused
by delayed admission to 1he hospital.
2. The Lnappropr;:,:::~-te treatment due to
lack of facilities in <the peripheral
hospi·tal and health centres.
3. The igno11ance of the pa,rents, for
example they wiJthdraw food or fluid
which they th1nk could increase the
di.an11hoea.
The primary and most important s'tep
in the treatment of ·acute gastroen,~·eritis
is restore the fluid loss (Ironside, 1970;
Rohde, 1974; Santhana Krishnan et al.,
1974), rats the majority of cases of acute
gastmem~:emitis is considered as a self-
limiting disease (Tumbelak,a, 1965; Bro-
towasis·to, 1974; Rohde, 1974).
At the beginni111g Riinger's lactate so-
lu,tioiTh was used 1n the treatment of
cholera, but according 1t:o Mahalanabis
et al. (1972), Ringer's lactate can be
used also m the treatment of acute non
cholera diarrhoea. The purpose of this
study is to prove the efficacy of Ringer's
lactate soLution (the cheapest 18J1'1d the only
available solution m the peripheral hos-
pital . arud rural health centres) in the
treatment of acute gastroenteritis witth
severe dehydration and acidosis as a
parenteral solution.
Materials and Methods
Fifty patiemt.s with acute iillfantile
gastroenteritis with severe dehydt\~lltion
and acidosis were hospitalized in the
 RINGER'S LACTATE FOR. GASTRO ENTERITIS 85

Depavtroent of Child Health Medical companyimg diseases can be seen in tables

School, Oniversity of I.ndones•i,a/Dr. Cipto
Mangunl<usumo Gene val Hosp~tal, Jakar-
ta. They consisted of 32 boys and 18
gids (Table 1) .. The age average was 8
mon<ths with the range of 1 - 18 months
(Table 2). The nutritional state and ac-
3 and 4. Sometimes in. one patient there
are 2 or more accompanying diseases.
To estimate the degree of dehydrati-
on, the scoring system. by Maurice King
( 1974) was ~sed as follows :

Score for signs and symptoms observed

Part of the body
examined

General condition
0

Healthy
I 1

restless, apath~tic,
I 2

delirium, stupor
sleeping or malaise or coma
Elasticity of the skin Normal decreased very decreased'·
E y e Normal sunken very sunk.en
Fontanelle Normal sunken very sunken
M o u t h ~ormal d r y very dry or
\.I·- .
,
cyanotic
Pulse rate per minute strong; 12Q- 140 more than 140
less than
120

The rsum of the scores of the above to Mangunkusumo General Hospital.

s•ilgns .and symptoms could be categorized Blood gas analysis .rund electrolyte exa-
as foltows: mination W1ere dcine <twice, Le. before and
after treatment.
0- 2: mild dehydration (5% deficit).
3- 6: moderate dehydration (8% defi- Method of the treatment.
cit).
The amoul11t of the Ringer's lactate
7- 12: severe dehydration (10% deficit). (RL) giv~n was as follows :
Laboratory examinations 1st hour: 30 ml/kg bw
the following 7 hours: 70 ml/kg b.w
Routine stool examination and screen-
or 10 ml/kg b.w./hour.
ing test for fat and su~ar dntolerimce
were done i:n the Department of Child After 8 hours on parenteral treatment,
Health. Blood gas analysis and <electrolyte ·the child was given oral solution, eHher
examination were donein ithe Depart- .glucose-eleCJ:.rolyte solution or milk for-
ment of Clinical Pathology, Medical mul'a in % dilution. If oral solution
School, University of Indonesi.a/Dr. Cip- . couLd not be given, parenteral. treatment
 HERNAWAN ET. AL.

TABLE 2: Age Incidence

TABLE 1 : Sex Incidence
Age (months) Total
S e x
I Total
0- 3 5

32
3- 6 9
Male
6- 9 20
Female 18
9 - 12 7
12 - 15 4

I
I
15- 18
18 - 21
5

I 21 - 24

TABLE 3: Nutritional state

Total

-Normal 38

- Under weight 12
-Marasmus

- Marasmic kwashiorkor

- Kwashiorkor
 RINGER'S LACTATE FOR 'GASTROENTERITIS
87

was co1n.tinued with Rlinger's lactate i!ll
5% Dex·trose. Clinical evaluation was
done including the general condiltion of
the child, the rehydration, blood gas
analysis and electrolyte examination.
Complication were also noted if prese1111t.
Result.
averaging 136 meq/1. potassium 4.7 and
chloride ion 100.5 mEq/l (table 7).
The results of •the RL administration
The result of the RL administration
was excellent in 44 (88%), good in 2
(4 %.) ·md poor in 4 (8% }, as can be seen
in table 5.

Accompanying Diseases Complication

Twenty seven (54%) out of 50 patients No c1ear complication such as over-

simultaneously suffered from other di- hydration and oedema occurred.
seases. They were upper .respiratmy tract
infection (5), Bronchitis (1), Otitis media Discussion
acuta (9), Infection of the gut (5), Fat
malabsorption (4), Sugar intolerance Among our patients, there were more
(2), Seizure (3) and V.S.D. (1). Some- boys than girls (table 1).
times in one patient 'there were 1, 2 or This ~an be explained by the fact that
more accompanymg diseases (table 4). usually boys are more active than girls,
so that the possibility of boys to get in-
Blood gas analysis fection is greater.
Before treatme:nt (IVFD), blood gas The age average was 8 months, with
f:lnalysis showed severe acidosis. The the ,rooge of 1 - 18 months. ThiiS can be
average of the pH was 7.30 with the unders1tood, because at this age, usually
range of 7.04 to 7 .48, whereas the average the infant gets additional food, so that
base excess was - 17 with the range the poss,ibiHty of contamination with
of- 8 to - 26 mEq/1. After treatment microocgamJsms is greater.
pH was 7.40 with the range of 7.27 to
Thirty patients (76%) were considered
7.57 and the average base excess was
normal and 12 (24%) unde,rweight. In
- 4 with the range of - 11 to + 5
this ·trial patient with P .C.M. were ex-
(table 6).
cluded due to the 'reason thEt:: in P.C.M.
there are so many factors (lactose and
Eleotrolyte findings
fat intolerance, overgrowth of bacteria,
Before IVFD, the average blood infestation of parasites, etc) which can
sodium concentration was 133 meq/1, ploay a.n impor(:a:nt and decisive role in
potassium 3.1 meq/1 and chloride ion ' causing diarrhoea.
83 meq/1. After IVFD, improvement After 8 hours on IVFD with RL as a
was obta~ned with the blood sodium parenteral solution, 44 patien$s (88%)
 •· HERNAWAN ET AL.
88

TABLE 4:
·. ,···:! '

-Upper Respiratory tract infection

I ·Total

5
- Bronchitis 1
.··:
- 0 . M. A. 9
- Infection of the: gut 5
-Fat malabsorption 4
-Sugar intolerance 2
-Fungal infection 2
- S .e i ·z u r e 3
'
-V. s. D. 1

* Sometimes there are more than 2 accompanying

diseases in one patient.

TABLE 5 : The results of the treatment

·!.

Excellent
''
I Total

44 (88%)
Good 2 ( 4%)
P o o r 4 ( 8%)

TABLE 6 : Blood gas analysis before and after treatment

pH
I Before treatment

7.30 ( 7.04 to 7.48)

I After treatment

7.40 ( 7.27 to 7.57)

BE -17 (-8 to -26) --4 (-11 to +5 )

TABLE 7: Electrolyte findings before and after treatment

Before treatment After treatment

Na 133 (117 160 136 (130 148

K 3.1 .( ;1,7 6.8) . 4.7 (. 2.1 6.5)

Cl 83 ( .70 115 .) 100.5 ( 82 115)

 RINGER'S LACTATE FOR GASTROENTERITIS
89

have ohtJaihed ·complete rehydration or tion inself because this chitd was admit·
have :CoOle irito a strute of only' niild cLe- ted · already in a moribund stage, The
hydratiaO. IVFD was stbpped and con- above findings were more or less simi-
tiJnued ~ith glucose-electro'lyt~ solution lar to the results of Mahalanabis et al.
or milk formula in % dilution. (1972).
Two patients (4%) still remained in F.rom this tdaf, it c.an be. concluded
severe ,d-ehydration af(:er 8 hours, but that RL solu1bion cruru be used in the treat-
after 24 hours of IVFD,, rehydration ment of acute gastroenteritis with severe
finally occurred. This can be understood, dehydmtion and acidosis as 1a pa.rertteral
because these 2 were in an u!!llderweight solution particularly in areas where
condition. Four patients (8%) still re- faci1lities and choice of parenteral fluids
mained in dehydration after 24 hours of rure limi1t:ed.
IVFD. One of :them improved only after
5 days .of IVFD. This can be explained .Acknowl~d~ements
that this case suffered from tprolonged
d1wrrhoea md vomitimg due to cholem The authors would like to thank
Eltor. . very much the Directorate General of
Three died, one due to encephalitis, Communicable Disease Control,, Ministry
one due to potasium deficiency (K = 2.1 of Health, for the supply of Ringer's
mEq/1) and the third due to dehydra- lactate and glucose electrolyte solutions.

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